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Three decades ago, in the early days of liver transplant, babies with
liver failure usually died. Transplants were saving the lives of adults
and older children, but were not offered to patients younger than 2. For
these youngsters, doctors thought, the operation was too risky and
difficult. But an ambitious surgeon named Carlos
Esquivel changed that.

At Lucile Packard Children's Hospital Stanford, transplant innovator Carlos Esquivel, MD, PhD, is celebrating the 30th anniversary of his first liver transplant and the ground-breaking procedures that have helped him save hundreds of lives. (Photo: Business Wire)

Now chief of the division of transplantation at Lucile Packard
Children's Hospital Stanford, Esquivel, MD, PhD, is lauded worldwide for
his skill at performing transplants in very sick babies and children.
But in 1984, he was just a surgeon-in-training who wanted a challenge.
He didn't know he would become both an advocate for pediatric liver
transplants and the leader of an extraordinary transplant team that
helps patients progress to healthier, happy lives.

Near the end of his surgical residency at UC Davis, the Costa Rican
native realized that his planned career in vascular surgery would not
challenge him enough. He sought a fellowship with the University of
Pittsburgh's Thomas Starzl, MD, PhD, who had performed the first
successful human liver transplant a few years before and was refining
the difficult, esoteric procedure. Soon, Starzl guided Esquivel through
a transplant on a man with acute liver failure who had come to the
hospital in a deep coma. The operation went well. Two days later, the
patient awoke.

"Once I saw that -- somebody who was at death's doorstep waking up -- it
was unbelievable," Esquivel said. "I never looked back."

Instead, he looked toward the babies who weren't being offered liver
transplants. Many had a congenital defect called biliary atresia,
which causes liver failure in infancy or toddlerhood.

"There are huge difficulties with transplanting these patients," said
Esquivel, who is the Arnold and Barbara Silverman Professor in Pediatric
Transplantation at the School
of Medicine. When the liver doesn't work, the blood doesn't clot,
increasing blood loss during surgery. The problem is worse for a small
patient who has less blood. Hooking up an infant's tiny blood vessels to
the donated organ is also difficult. And these children are small for
their age because liver failure hampers growth. In short, said Esquivel,
"Patients with liver failure are some of the sickest in the hospital."

But without transplants, they invariably died. So Esquivel began trying
to transplant them. At first, about 70 percent survived.

"Going from 100 percent mortality to 70 percent survival was a huge
improvement," Esquivel said. He published his results in 1987 and began
advocating that infants and small children should be offered the
benefits of transplant.

"The whole ield was just undergoing a revolution," said Starzl, now
professor emeritus at the University of Pittsburgh. Esquivel's
scientific inquisitiveness and warm, sensitive character made him a good
person to advance the field's transformation, Starzl said. But it was
his surgical skills that really set him apart.

"He is instinctively a tremendously good surgeon," Starzl said. "He has
the kind of virtuoso qualities that you can't teach." Those skills
allowed Esquivel to consistently reconstruct the tiny blood vessels and
ducts that feed the liver. "It takes a different level of skill than is
required for adults," Starzl said.

From Pittsburgh, Esquivel moved to San Francisco's Pacific Presbyterian
Medical Center (now California Pacific Medical Center) to build a
multidisciplinary team that addresses the many facets of transplant care.

In 1995, the team came to Lucile
Packard Children's Hospital Stanford, and built a program now
recognized as one of the largest and most experienced in the world. They
have performed more than 600 liver transplants, including some in which
patients also received another organ, such as a heart, kidney, lung or
intestines.

In 2013, the team achieved 100 percent one-year survival for their liver
transplant patients, a rate that is higher than expected given the
acuity of cases they undertake. Their advances include developing
regimens of immunosuppressive drugs with fewer side effects; offering
liver transplant for new indications such as inherited metabolic
diseases; and pioneering a clinic where teenage transplant recipients
learn to take responsibility for their own care.

"We have been able to put together an unbelievable team," Esquivel said.

Meanwhile, Esquivel still cares for the tiny, fragile babies who
inspired him decades ago. Biliary atresia is still the leading cause of
childhood liver failure, and many hospitals still turn down difficult
cases.

One of these was Zachary Teczon, whose health was deteriorating quickly
when the team decided that, at 7 months old, he could wait no longer for
a liver transplant. In an operation that made use of all of Esquivel's
years of surgical innovation, Zachary received his new liver on January
28, 2012. After months of watching Zachary get sicker, his mom, Jennifer
Delia, will never forget how she felt that day.

"I was scared but happy that he was going to have a new life," Delia
said.

The next day, she was relieved and elated when Esquivel came out of the
operating room to tell her that Zachary's operation was a success.

For Esquivel's part, he's grateful to see transplant recipients grow and
thrive. He loves getting messages from the families of young people, now
in their 20s, like Kelly Olmo of Oakland, who was one of his earliest
patients when she received her transplant 25 years ago at age 2. Hearing
about the lives of former patients like Kelly - and the joy their
families feel from watching them grow - convinces him that the
difficulties of being a transplant innovator are worthwhile. "It's very
moving," he said. "It's really the best possible reward."

Stanford Children's Health, with Lucile Packard Children's Hospital
Stanford at its core, is an internationally recognized leader in
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Lucile Packard Children's Hospital Stanford is the heart of
Stanford Children's Health, and is one of the nation's top hospitals for
the care of children and expectant mothers. For a decade, we have been
ranked as the No. 1 children's hospital in Northern California,
according to U.S. News & World Report's 2014-15 Best
Children's Hospitals survey, and are the only hospital in
Northern California to receive the national 2013 Leapfrog Group Top
Children's Hospital award for quality and patient care safety.
Discover more at stanfordchildrens.org.